Healthcare Provider Details

I. General information

NPI: 1972719789
Provider Name (Legal Business Name): MARIE ELAINE DEGROATE COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3405 CAMPBELL ST
VALPARAISO IN
46385-2363
US

IV. Provider business mailing address

151 SPRINGWOOD DR
HEBRON IN
46341-7214
US

V. Phone/Fax

Practice location:
  • Phone: 219-462-1023
  • Fax:
Mailing address:
  • Phone: 219-988-7284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number32000984A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: